Initially, this discussion started with what
appeared to be a case of idiopathic hallux
varus. Now, it has progressed or digressed into
a discussion on the basics of what I like to
call BIOMAJIC. Root vs. Shavelson(FLEB). I do
not claim to be a biomechanics expert or an
innovative thinker. I do claim to have years of
experience in surgery which requires a sound
understanding of the way the foot works. What is
successful in some does not work in others.
Biomechanics principles should be used as a
teaching tool for students and practitioners.
Biomechanical principles are simply theoretical
tools as much as we enjoy arguing about them. My
advice to the younger podiatrists is to learn
ALL the principles-- you will find out that
every patient is different from a surgical
standpoint and through training and experience
you will learn how to apply the principles.
One of the several topics that I feel strongly
in disagreement with is the “postopthotic.” I
can tell you from my experience generally if you
do not fixate an osteotomy of the foot, you will
get more non-unions—the idea of letting the
bones seek their own level has failed in my
hands and many others. The idea of putting a
post-operative patient in some orthotic for 3
weeks as I understand a “postopthotic” is just
does not make common sense from a practical and
medical standpoint.
I get my best results when I perform osteotomies
by doing a complete preop evaluation looking at
both the rear foot and forefoot on each
individual, performing the osteotomy checking
position on the table and fixating the bone in a
position that I determine to be the best. I
don’t think that there will ever be a formula
for that.
Dr. Cohen, one of the original posts on this
case, suggested multiple minimal incision
nonfixated osteotomies for this case which would
be a disaster in my hands. Perhaps Dr. Shavelson
believes that a postopthotic would change that.
If so, I would like to see some studies that
support it.
Tip Sullivan, DPM, Jackson, MS,
tsdefeet@MSfootcenter.net
While I agree with post-op orthotic concepts
with respect to hallux valgus correction
maintenance long-term, and appreciate Dr.
Shavelson's point of view, one is hard-pressed
to agree that an orthotic provided within the
initial 2 week post-op period has ANY positive
impact on osteotomy alignment, asclearly implied
in Dr. Shavelson's post.
On the contrary, I'd opine the biomechanic
reality is that NO orthotic is capable of
stabilizing an unstable osteotomy site! So, if
osteotomy stability was never achieved on the OR
table, then how it heals, with respect to 1st
ray alignment, becomes a DIRECT function of its
orientation and the effectiveness of the
stabilization method utilized (or lack thereof)
to maintain it during the healing process, NOT
whether one adequately re-aligned the hindfoot
for a few weeks.
The other major variable is the type of
osteotomy performed, and whether it was adequate
enough to address the deformity in the first
place.
In addition, it would take YEARS, not weeks, for
the negative effects of poor biomechanical
function to negatively affect a surgical
outcome. Additionally, those ill effects
wouldn't occur at the osteotomy level, it would
occur proximal to it, where STJ planar dominance
and its resultant instability from lack of post-
op orthotic adherence LONG-TERM would allow
those deforming forces to re-create the forefoot
instability responsible for those structural
changes. The severity of those deforming forces,
the patient's life style, and time line involved
when the surgery was initially performed, would
dictate whether structural forefoot deviation
would recur to an extent that a 2nd surgery is
required.
I believe those of us who have performed bunion
surgery long enough to have 20+ years of follow-
up would vouch for that statement, irrespective
of one's biomechanical views/preferences. For
instance, I appreciate that my few failures
occurred either when I wasn't aggressive enough
in my original osteotomy choice, orientation,
OR, under appreciated the extent of those
biomechanical deforming forces, OR failed to
adequately connect with my patient regarding the
long-term importance of adhering to that post op
orthotic protocol.
Lastly, with all due respect to Dr. Shavelson,
who is a wonderful podiatric advocate of
orthotics and how they impact FLEB, for the most
part, in my experience, "Rootian" biomechanics
works VERY well! Sometimes, we simply miss
diagnose/under appreciate major structural mal-
alignment, or resultant functional weakness in a
given foot type. This may lead to a poor
orthotic choice. Frankly, that's not Root's
fault...it's ours!
Barry Mullen, DPM, Hackettstown, NJ
yazy630@aol.com
